Form Dr 7189 - Gasoline/special Fuel Tax Refund Permit Application Page 2
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3IV. Provide a brief description of your business and detail how the fuel is used in your business for exempt and
non-exempt use.
V. If you have checked the special fuel box in Section II, please answer the following questions:
□
□
1) Is the special fuel (diesel) being placed in the tank of a vehicle with a current license plate?
Yes
No
2) Is there some other activity (such as operating a cement mixer) that uses fuel taken from the same tank?
□
□
3) Is the vehicle(s) licensed for IFTA?
Yes
No
In what jurisdiction? ____________________________________________________________________________
NOTE: Fuel used in vehicles licensed and plated for on-road use does not qualify as exempt fuel. The only exemption
is fuel used as a power source for a qualifying exempt purpose other than powering the vehicle on the road. Also, no
refunds on dyed diesel are allowed.
VI. List all the equipment and vehicles using the fuel you purchase. If additional space is required, attach a separate
sheet using the same format. You can attach your own vehicle/equipment list, if all the required information
is provided: (If fueling from bulk storage facilities - list all vehicles and equipment fueled from the fuel supply
storage).
Miles
I.D. number or
Reported
Make & Type of Equipment
Equipment Use
Model/Year
License Plate
Fuel Type Used
on IFTA
Number
Return
(Y/N)
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Parent category: Financial